Dr. Patricia Cuff, National Academies of Sciences Global Forum on Innovation in Health Professional Education: Fostering a Multidisciplinary Approach to Improving Healthcare

Van Ton-Quinlivan

Hello, I’m Van Ton-Quinlivan, CEO of Futuro Health, welcoming you to WorkforceRx where I interview leaders and innovators for insights into creating a future-ready workforce.

Today, I’m delighted to welcome Dr. Patricia Cuff of the National Academies of Sciences, Engineering, and Medicine to the podcast to gather her insights on the current and future state in the education of healthcare providers.

As forum director of the National Academy’s Global Forum on Innovation in Health Professional Education, Dr. Cuff helps lead an ongoing conversation with academic experts and practitioners that evaluates promising innovations across the learning continuum from education to practice. Dr. Cuff also contributes her own research to the field and is currently coordinating workshops on the future of pharmacy education and practice, and the affordability of health professional education. Thanks very much for joining us today, Patricia.

Patricia Cuff

Thanks so much Van, it’s really terrific to be here and I really appreciate the invitation. Thanks.

Van

Absolutely. Well, let’s start by having you share an overview about your work at the Global Forum on Innovation in Health Professional Education.

Patricia

Super, yeah. So, you know, I kind of chuckle when I get this question to ‘tell me about the Forum’ because it’s a question that my mother has been asking me repeatedly for over a decade now.  I think the easiest way to explain it is basically I bring people together who are passionate about providing the best healthcare possible to patients and populations, as well as those who are passionate about educating the next generation of care providers, as well as the current health workforce, but also educating the faculty themselves.

So what we do at the forum is we provide a platform for our fifty members to come together. They represent sixteen different health professions. So we have medicine and nursing, but we also have dentistry, social work, mental health counseling, optometry and a whole host of other health professions represented on the forum. They are educators. They could be faculty, deans, provosts. We also have accreditors on the forum, as well as administrators of health professional and education associations. But the members are not just educators, they’re also practitioners. Not only are they educating, but they’re also providing care. So, a lot of our conversation is about the bridge between education and practice.

Now I did say that our main focus is to bring people together and the way we do that is we have small groups that come together across professions to incubate ideas and to take those ideas and to come together to plan our workshops. The members themselves agree upon the topics.

All of our workshops are free, they’re open to the public. They’re in-person, but they’re also virtual, so we can expand our reach to reach as many as possible, and some of them are actually extremely popular. We’ve gotten 900 to over 1,000 registrants to some of our workshops. It won’t surprise you that recently we ran a workshop on artificial intelligence, which was really one of our most popular workshops. And when we were preparing for the workshop, we spoke with an educator in an engineering school — this is kind of an interesting story — he developed a chat bot and told the students in his class that the chat bot was the TA and her name was Rachel and the students were to use the TAs if they had questions.

At the end of the class, he sent out an assessment: how did you like the different TAs? Well, actually, Rachel scored very well among the students, because he was responsive at all hours of every day, she was consistent and she never got upset, even if they asked the same question multiple times. So actually at the end of the class, the students really wanted to nominate her for an award for being one of the best TAs, which everyone thought was funny. But the idea being that the educators have to educate the current health workforce, of course, as well as the learners about AI, but also AI can be used as a tool for the faculty themselves to be able to help lighten their load a little bit.

So I’ll just say that one other very popular topic was meeting the needs of an aging population. Now that topic I think is critically important because of the demographics that are happening. We have more people reaching 100 years of age and older, and we really need a health workforce that understands the needs of an aging population. So again, I just want to emphasize again that it’s the members themselves that decide upon the topics. So they really have the ear to the ground and they can understand what are the critical issues facing education and healthcare workforce today. So, that’s kind of the forum in a nutshell.

Van

Well, the two examples that you mentioned are super interesting. And of course they’ve come up on my radar, even just this last week, both the AI topic and its application into learning and healthcare, as well as meeting the needs of the aging population. So, when you get fifty stakeholders together in a meeting, my goodness, how do you generate the ideas?

Patricia

Yeah, well, the ideas are really generated in the small groups, as I had mentioned before. We come together twice a year with just the members. We hold our workshops as well twice a year, but just the members come together and they talk about what’s happening on the ground. What are the challenges that they’re facing and what are the issues that they need to address? What are those issues that rise to the top that they see as critically important to the work that they do, but also to the work that others do. And so that’s why we open our doors and we let others in to see some of the planning that takes place or some of the outcomes that take place from these small group meetings.

Van

So you mentioned, for example, the chatbot, which was much more friendly and more patient than maybe the live human being. You could extrapolate from the students’ experience to see how that could be applied in health care, for example. What are some of the lessons learned that you would like others to replicate?

Patricia

You know, as I think about it, imitation is the greatest form of flattery, right? But, you know, I’m not sure that I necessarily want others to replicate or imitate the work that we’ve done. What I would prefer is for people to build upon the foundation that we’ve laid.

If I can give an example of that, last year, we took the show on the road to Pennsylvania, and we worked with the University of Pennsylvania’s Penn Dental Medicine. It’s an interprofessional education program that is run by Dr. Mark Wolf, and his focus is providing good, interprofessional preventive oral health care for persons with physical and mental disabilities. What we found is that really every health professional has a role to play in  maintaining good oral health and has an advantage to working with patients who have good oral health. So for example, the nutritionists have a role in maintaining good oral health by monitoring the diet and making sure that there aren’t too many sugary foods being eaten. The occupational therapist can work with persons with disabilities on their manual dexterity and come up with toothbrushes so they can brush their own teeth. And then something came up which I hadn’t heard about before, which is dentophobia – a  fear of dentists. That’s something that the psychologists have actually been working with.

Also to kind of bring this together with the whole notion of interprofessional care, we uncovered the fact that the health records for medicine do not communicate with the health records of dentists. They’re inoperable. So even if the dentists and the medical directors and the doctors wanted to work together, they actually would not be able to interact using their medical records. And then if you also think about it, if you ever have a toothache and you go to the hospital, they really can’t do very much for you. There’s no interaction between medicine and dentistry.

Now in this is the workshop that we ran up in Pennsylvania, we did hear about a dental hygienist at a small hospital in Oregon. And while the hospital isn’t paying for her, she does have funds to be able to support her position part-time and she has done an incredible job in being able to facilitate the interaction between the mouth and the body. The whole idea that the mouth is not part of the body is ridiculous. We talked about mind, mouth, body, and soul.

She was able to help one patient in particular who was an elderly woman who wasn’t eating post-operatively, and they really needed to get her to start eating so they could discharge her. She found out the reason this woman wasn’t eating was because she had pain in her mouth. She had a toothache and so she was able to help with that, alleviate the pain, get her eating, get them out of the hospital and give her a referral to the dentist.

So I just wanted to say that these are the sorts of things that we’re addressing. So in a sort of long-winded way of getting to your question, I guess if there was one item that I would like to be replicated, it would probably be our truly interprofessional approach that we take on the Forum, where all the health professions have value, everyone has a voice on the Forum, and everyone’s considered an important part of the team. And I just will point out that this is actually quite rare in education as well as health care, where everything tends to be much more siloed.

Van

That is a good point. I had not heard of the word interprofessional until I chaired the California Health Workforce Education and Training Council. So this word actually is so unique to the health care arena. And I’m wondering if, by having your members be as diverse as they are from different disciplines, does that allow them to solve problems differently or see a problem space differently?

Patricia

Yeah, I think that puts it really nicely, When you get into a silo, you see things very myopically and it’s hard to think outside of the box and I think that what this does is it allows the different health professions to learn from and with each other. That’s really the whole notion behind interprofessional…it’s learning from and with other health professions. Ideally, what we’re doing is we’re educating interprofessionally so that when going into practice, the students know how to collaborate with other health professions.

Actually, let me give you an example. Let’s say you’re running a clinic and you have a patient who comes in who’s overweight and has diabetes. So ideally, the team will collaborate around this patient towards a goal that will benefit the patient. So for example, the pharmacist or the medical doctor might be in charge of the person’s medicines. The dietitian would be in charge of the patient’s diet. The exercise therapist would then come in and work with the patient’s activity level, and if they need social services, we could have a social worker or a case worker. And then there could also be a nurse or a physician assistant who would then manage the care and monitor the vitals and sort of manage the whole case.

The idea is like a baseball team in a sense, that everybody has a position on the team. Nobody stands out as being more important than the other. It’s non-hierarchical, but everybody has to come together for the benefit of that patient and really work towards a common goal to be able to have the best care for that patient. It’s not uncommon that you might go in to see one health professional and then you go to another and they ask you the same questions. So the idea is how do we work together with the patients?

I will just say that this is actually quite rare, to see this sort of interprofessional collaborative practice. Studies have shown that people think they’re working interprofessionally, but when you actually look at them and monitor them, what you find is they’re working next to each other. If you think back to childhood,  two-year-olds don’t play together. They have parallel play and that’s how it’s been described in the workplace, that often the care providers are working side by side, but not interacting. Or, they’re educating their learners, sitting one right next to the other from different health professions. But unless you have them interacting and working towards a common goal, you’re not truly interprofessional. So what I would like is for people to really understand the importance of working together towards that common goal.

Van

Patricia, maybe for all the listeners who are not from healthcare or even higher education and healthcare, the interprofessional approach is a means towards an end, right?  I was wondering if you could just spell out what is the intended end of working interprofessionally?

Patricia

What a great question. So I would say, and I think others would agree with me, that the goal really depends upon the patient themselves. When we talk about an elderly population, we don’t always have the same goals in mind as we would with someone who’s quite young and vibrant and has the whole world in front of them. If they have particular disease, their aim may be ‘let’s hit it hard, give me every medicine you’ve got, I’m gonna fight this thing, I’m gonna get over this.’ As we get older, the desire may be less focused on giving me the strongest medication so I can hopefully beat this thing…it may be more towards can you make it so that I feel well enough to take care of my grandkids. That’s what I really want in my life.

So, it’s key that there’s an understanding of what it is that the person themselves wants — what is that person’s goal, what do they want out of their life — and have the team form around those goals. I think that is really the essence of interprofessional, that the team leader is really the patient as opposed to someone who’s a healthcare provider. This is especially important because many healthcare providers have been trained to try to treat every disease to the ultimate regardless of the side effects of the medication. They just try to extend the life of the person, which for some people is exactly the right goal, but for other people, the goal may be different. So that’s how I see interprofessional care.

Van

So Patricia, tying it back to you prior comment about meeting the need of aging populations…in my head, I automatically jump to dealing with chronic diseases. But you’re not talking about just that. Based on your explanation just now, it’s about a more patient-centered approach and team-based care. I’m actually loving all your examples, so are there some other examples of how you might slice and dice this topic of meeting the needs of the aging population?

Patricia

Yes. Funny you should say that. Someone has just recently joined my Forum, and this is a spin off on the workshop that we ran on meeting the needs of an aging population. One of the things that we uncovered through that workshop is that aging begins really the moment you’re born, and some people on that workshop planning committee wanted to say, ‘well, it begins in utero.’ That was kind of a step too far for me, but I do believe that it does begin in childhood because the decisions that you make in childhood are going to affect you as you get older. You may not feel the impacts when you’re in your 20s and your 30s, but as you get into your 40s, 50s, 60s, those decisions that you make as a young person actually impact what it is that you’re able to do.

It’s really about the foundation that you lay as a child and a young person. Do you exercise? Do you eat healthy foods? And those can really come back to haunt you as you get older. What we’re setting up now is one of these small working groups to focus more on healthy aging because I think this is really going to be the narrative of the future…that we’re going to be looking towards not so much trying to treat every disease that comes along, but to try to prevent those diseases from occurring in the first place, prevent those bone breakages that could be avoided if the diet was well-maintained and there was exercise and so forth.

So the way I see it, meeting the needs of an aging population is not only understanding what it is that the person themselves wants out of their life, but also looking at aging across the life course of a person.

Van

So, pulling on that thread, what you hope to do is also prevent that person from needing to go in and see the doctor. Maybe there are different kinds of healthcare workers, or maybe they’re not even healthcare workers, that do the work on prevention, I would imagine. So, if you had a crystal ball on where the future would go with regards to the care workforce associated with healthy aging, tell us what your thoughts would be.

Patricia

Yeah, so let me look into my magic eight ball and think about this. Where do I think it’s going? Well, I think we have to start in the present because right now we do not have an adequate health workforce to take care of the needs of the current aging population. We just don’t have it for a variety of reasons. It’s not a major that a lot of health care professionals want to go into. One of the things that we learned is that even if the courses are offered for the learners, quite often they don’t take them. It’s just not seen as prestigious. It’s not seen as cutting edge. So I think what we need to do is start thinking about the current health workforce because what happens is the graduates, the learners don’t see the value in it and don’t pursue any education in it.

It’s not uncommon that the courses get dropped, so you don’t even have the education. And then what happens is the learners graduate, now they’re in the health workforce, and they suddenly realize, actually, 80 % of the population that I take care of are older adults and I never learned how to care for an older adult, which is quite different. It’s more complex, it has more social issues. And as I said before, it’s not always about what you learned in school as the best treatment being the best option. It’s really what the person wants. Quite often, it takes more time to work with that person. So what we need to do is educate the current health workforce to be able to take care of the aging population, and maybe we need to require that all learners understand how to take care of an older population, similar to what we do in pediatrics.

Pediatrics is often required in all of the majors, but geriatrics is not. So, trying to see if it’s possible to include that as part of the accreditation process, I think would go a long way to forcing learners to understand that they’re going to be taking care of older populations so you need to understand their unique needs, but also you need to understand how to work with them as a unique population.

Van

Well, certainly when you look at the demographics of America and the growth of the 65-plus population, you are right. We need to get much more ready for geriatric care. And so when it comes to the interprofessional approach, are there some institutions or organizations that do that kind of upskilling that you’ve talked about particularly well?

Patricia

Yeah, there is. There’s a group through the Veterans Administration that actually has done a really terrific job. They’ve put together an educational program that was really meant just for the VA, but what the person involved with the program told us was people were calling her constantly asking for the educational materials that they’ve developed. She was very surprised that this wasn’t learned earlier on in the education, that she was having to provide so much education to people after they’ve gotten into the health workforce. So I think that’s very telling there, that this is a gap in health care providers as well as education that I think really does need to be addressed.

Van

You are also coordinating a workshop on the affordability of health professional education. What are you learning through that body of work?

Patricia

That’s great question. We’ve run three pre-workshops already. The workshop itself is taking place at the end of April. The first pre-session that we ran was looking at whether cost is a barrier to entering into the health professions. That was our first question that we asked and basically what we uncovered was it really depends upon the health profession itself. Some of the health professions have a very strong return on investment, whereas others actually are demonstrating a weak return on investment. Do students have to take out loans in order to pay for their education? Does the salary compensate for the amount of money they have to take out in those loans?

I will say across the board, pretty much all the health professions require a bachelor’s degree. Now what we’re seeing is that most, if not all, are requiring a master’s as well as a doctorate degree. And what happens there is not only does the student often take out a loan for the bachelor’s degree, but they have to take out even more of a loan to get the master’s and the doctorate. What we uncovered in the first pre-workshop that we ran was that as the requirement increases for the higher level of education, the lower the return on investment for entering into that health profession. That’s actually very telling as many of the health professions are having what they’re calling a “degree creep” where they’re requiring higher and higher levels of education. But are the graduates being compensated? Are they able to pay off their loans after they graduate?

Now, as I said, it’s really dependent upon the individual health profession. There are also health professions that actually have a very high long-term earning potential, and it’s the ones that you might imagine — there’s medicine, dentistry, nursing. Those are the three that really kind of stand out. And they’re grappling with different sorts of issues. Like, is cost a barrier for all the potential applicants to come into the health profession? Or is it just those who have the means to be able to get a loan and to be able to have that loan taken out?

Dentistry is the most expensive of all the health professions so the graduates end up with a large debt, probably the largest debt of all the health professions. The difference for dentistry is that within seven years, they actually pay off their loans, so the return on investment for going into dentistry is actually quite good. But if you were to just assess them the very first year they graduate, their return on investment looks terrible. It’s similar with medicine. If you look at that first year when they’re doing their residency, their salary is low and their debt is very high, so it looks as though it’s a terrible return on investment. But actually, if you look at the long term, it’s actually quite a good return on investment.

Now, what I’ll say about those is that the question kind of comes down to is cost a barrier to entering into primary health care? That’s an area that is diminishing in numbers and it’s a tremendous need for the population around the US and around the globe. But what we’re finding is that more and more graduates are going into specialty care and not primary healthcare. So the question is, is cost a barrier to going into primary health care? We’re exploring that question.

Now with dentistry, it’s not a barrier to going into primary healthcare. Eighty percent of the graduates actually go into primary health care because the return on investment for specializing is not that great for dentistry. Their issue is not going into primary care. Their issue is being able to provide care for the entire population. What you find is that the dentists are grouped around urban settings, but if you go into a rural community, there are very few dentists available. That’s why I was pointing out that one rural hospital in Oregon because being able to employ a dental hygienist was actually quite impressive.

I’ll just say one more thing is the nurses actually have probably the best return on investment of any of the health professions because quite often their education is paid for. They can start in the health workforce really at the bachelor’s level, at the master’s level, the doctorate level, and the salaries are actually quite competitive. So they end up with not too bad of a loan, not too bad of a debt, and a decent salary. So what we’re seeing is enrollment for medicine, dentistry, and nursing is actually quite strong, whereas some of the other health professions that have a weaker return on investment, their enrollment is in some places a little on the scary side.

Van

Patricia, in terms of shortages in the primary care workforce did you look at some best practices when it came to structuring, for example, loan forgiveness or financial aid such that you could attract or grow your own from your own community?

Patricia

That’s a great point. Absolutely. Yes, loan forgiveness programs work extremely well. The graduate has to be willing to put time in back in service. I think one of the best returns on investment is the military. Now for medicine, they pay for all of your education and you give back, I believe it’s 10 years. In nursing, similarly, they pay for all of your education and then you’ve got a service requirement of something like seven years. I don’t have that exactly right, but it’s a lesser commitment than for physicians. But you put in your commitment and then you’re free to re-up with the military or you can then go into the civilian world. There’s also other programs where you can get loan forgiveness by going into serving in rural populations, and that’s huge.

One of the challenges in that regard is getting people to stay in the rural populations. Even if they want to stay, these are often young people who are starting their lives and sometimes in a rural area, it doesn’t have the infrastructure that they might need, for example, to put their child into the best schools and have the sorts of resources that they would like to be able to have to start a family. So, those are some of the challenges.

Van

Well, I want to give you a chance to take a look at the future of care and the future of caregivers and I would love to invite you to impart any last thoughts to our listeners.

Patricia

You know, I think in the future, one of the key issues that we’re going to have to be dealing with is stress and burnout. This is actually one of the largest, if not the largest, issues facing the health workforce today. We’re graduating the eager students who want to join the health workforce, and then we’re putting them into a system that emphasizes the business model of health care. And in doing that, we’re focusing in on the numbers. Get them in, get them out. The medical health record is actually not so much a medical health record as a tool for billing. And trying to ask people to do more with less resources at a faster rate is a recipe for burnout and stress.

I think what we need to do in the future is really get a handle on meeting the needs of the health workforce so that they can get back to providing the sorts of care that they were trained to provide, and that they want to provide, and the reason that they went into the health professions in the first place.

Van

Perhaps we can get some of those bots you mentioned earlier on to do some of this billing paperwork so the joy can be brought back into healthcare.

Patricia

I think those plans are underway.

Van

Well, Patricia, it was a delight to have you. Thank you, Dr. Cuff, for joining us today.

Patricia

Thanks so much, Van. I really enjoyed the conversation. We’ll talk again soon, I hope.

Van

I hope so as well. I’m Van Ton-Quinlivan of Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.